Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
How would you approach a biopsy proven NSCLC patient with mediastinum negative disease and contralateral suspicious spiculated PET avid nodule without pathologic diagnosis?
This is a scenario I have faced before. Sometimes unfortunately in spite of staging studies, the stage a lung cancer patient has might remain a bit unclear. In this situation if this is a functioning patient with good PFTs who is a surgical candidate I would consider treating him like he has 2 separ...
Do you alter definitive treatment recommendations for oropharynx p16+ cancers based on the new staging?
As you know, the new 8th Edition of the AJCC staging manual redefined prognostic staging for p16/HPV-positive tumors. It is important to note that p16/HPV is therefore not a PROGNOSTIC marker but rather a DIAGNOSTIC biomarker of a different disease entity entirely. The 8th Edition system is based of...
Does size influence your decision making for women with low or low-intermediate risk endometrial cancer after hysterectomy?
In otherwise low risk disease where I would favor observation, I do discuss pros and cons of adjuvant cuff brachytherapy if size greater than 2.5 cm or so.
When is adjuvant radiotherapy recommended for a high risk squamous cell carcinoma of the skin (non-H&N) if the tumor is resected with widely negative margins and there is no perineural invasion?
There is limited high quality evidence to guide management of "widely" excised cutaneous squamous cell carcinomas. There is an excellent prospective study reporting the outcomes of margin-negative excisions using techniques similar to Mohs surgery suggesting that there are several risk factors for l...
How long after surgery would you no longer offer adjuvant postoperative treatment for head and neck cancer when a patient (with multiple adverse features that needs adjuvant treatment) keeps postponing the start of radiation?
Ultimately, I feel this depends on why the patient keeps postponing treatment. If there are legitimate medical reasons for delay, I would not have a cutoff for starting adjuvant RT at any time - even several months after surgery - as long as the patient can tolerate curative-intent therapy and I hav...
What fractionation would you recommend in a patient with recurrent early stage breast cancer who has had prior lumpectomy and IORT and refuses mastectomy?
While there is no standard of care, several options exist. It is important to delineate where recurrence is (true recurrence vs. elsewhere failure in breast). Also, IORT technique is important a low energy IORT (50 kv) has limited dose deposition beyond a few mm (5-6 Gy at 1 cm) and as such much of ...
What factors do you consider when electing to observe small brain metastases (vs treating with SRS)?
Since I see primarily brain metastases from lung cancer, my opinion will be confined to small cell and NSCLC brain metastases. For single or multiple small (and I am going to assume that they are asymptomatic) that are present at the diagnosis of small cell lung cancer, I think it is reasonable to ...
When would you recommend surgical debulking of pelvic or para-aortic lymph nodes in cervical cancer prior to definitive chemoradiation therapy?
We have not favored dissection and treated with SIB and sometimes added sequential boost ( EQ@ dose 58-66 Gy) based on sizemost current literature shows excellent regional control but high distant failure in these ptsfor bowel and duodenum ( two organs which could be limiting factor) we use v55 dose...
For patients with stage I NSCLC initially treated with SBRT, how do you best manage isolated regional nodal failure?
The 5-year loco-regional failure rate in RTOG 0236 was 38%, underscoring that there is considerable need for identifying a post-SBRT salvage strategy for these patients; there are only anecdotal reports in the literature as to how to best manage these patients. Our historic approach when the failure...
How would you approach oligometastatic (solitary) recurrence with previously resected pancreatic adenocarcinoma and adjuvant chemotherapy with a prolonged disease-free interval?
This is very different from colon cancer with a solitary recurrence after a long disease-free interval. In this case, before considering any local therapy, I would treat with a course of systemic therapy to establish favorable disease biology. The vast majority of patients with recurrent, oligometas...